This gut worm is more common than malaria—and it’s a deadly, ticking time bomb

Researchers call for more awareness as some populations face 60% infection rate.

A deadly parasitic worm that quietly inhabits the guts of humans the world over has, according to some researchers, been the most neglected of the neglected tropical diseases—and health experts are finally hoping to raise its profile to stamp it out.

Infecting an estimated 370 million people, the tiny worm surpasses the worldwide reach of malaria each year. And in the right conditions, it can abruptly turn deadly, Australian health experts note in a commentary this week on The Conversation. Though it’s largely linked to the developing world, it can make its way into anyone, anywhere. In some Indigenous Australian communities, the infection rate is as high as 60 percent, the experts report. And it pops up in disadvantaged areas of the US and Europe.

The worm is Strongyloides stercoralis, a “threadworm” nematode that causes strongyloidiasis. S. stercoralis has a peculiar life cycle that involves unfortunate humans coughing up, then swallowing larva after they invade the blood stream. From there, adult S. stercoralis discreetly inhabits mucus tunnels in the small intestines, sometimes for a person’s whole life. It often causes no symptoms. But when it does, symptoms are often mild and vague, such as cramps, diarrhea, weight loss, or a rash.

That all changes if the infected person suffers a blow to their health that compromises their immune system or if they take immunosuppressive drugs, such as some steroid drugs. In those cases, the worm can abruptly cause a life-threatening “hyperinfection” and spread throughout the body. In a hyperinfection, the worm’s reproduction shifts to ludicrous speed, resulting in an overwhelming number of worms. These can disseminate, spreading far beyond the intestines, causing massive full body infection. A disseminated hyperinfection can cause death in up to 87 percent of cases.

A parasitic drug called ivermectin can defeat the S. stercoralis, but it may be a tough battle. Some worms are showing up with drug resistance now, researchers report. And if a single worm remains, it can asexually reproduce and reignite an infection. Also, the immune system doesn’t develop an effective response to the worm, so a person can be re-infected.

It’s unclear how exactly S. stercoralis survives in environments to infect or reinfect a human host. But researchers think it can survive for a long time outside, including in contaminated soil or water. Researchers think it often enters a host through skin—it burrows in and makes its way to the bloodstream. Once there, it hitches a ride to the lungs, where it gets coughed out into the throat and swallowed. The worm then settles into the small intestines.

S. stercoralis is tricky to detect in humans. Blood tests for an immune response to the worm can be inaccurate. And searching through stool for worms can also result in false negatives because the worm is not consistently shed into feces.

Taken all together, there are too many questions, unknowns, and infections to ignore, the Australian health experts conclude. They call for more research on the worm’s spread and drug resistance.

“However, the biggest challenge in fighting this disease,” they write, “is that many people have not even heard of the strongyloides worm.”

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Well, I can confidently say that having lived a significant portion of my adult life in developing world tropical environs, that was a terrifying article.

I'm going to guess East Asia or maybe South America. Talking to people that go to Africa regularly for missions or Doctors w/o Borders work, getting all kinds of parasites is pretty much par for the course until you've done a couple tours and developed some immunity.

What Happy Medium wrote. This organism sounds like barely more of a problem than E. Coli, maybe less of a problem than H. pylori. Any kind of global treatment plan could easily be worse than the "disease".

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

I guess the most story worthy aspect of this is that here is something living in people who may never know they have it - and we have no solid way of detecting it or treating it... Mother Nature is lit!

Got to love the way you immediately defuse the potential for hysteria by belittling the Strongyloides parasite to 'strongy'

[Alternative explanation: you are Australian, and therefore *everything* becomes shortened as a matter of course, as 'Good morning my good man/woman' becomes 'G'day', and 'Can of fizzy lager' becomes 'tinny']

Used to live in Africa when I was a kid, where what we called bilharzia (formally: Schistosomiasis) was drummed into us from an early age - swimming in open water was a Very Bad Thing and pretty much guaranteed to lead to infection. Very similar-sounding to what this article describes, although more obvious symptoms of infection - and despite the frequent warnings, as kids we always knew someone who was on medication to get rid of 'em.

That rambling intended to say that: parasitic worms are more common that you'd think, and even when they're well-understood, hard to avoid.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

..But the article does point out it can flare up and cause diarrhea, cramps, etc.

As some of the specific triggers of Irritable Bowel Syndrome (or anything that is diagnosed under that umbrella) may be unaccounted for, isn't it possible that there may turn out to be a link between a S. stercoralis and IBS?

Such a link could finally help to explain a lot of things for many people.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

..But the article does point out it can flare up and cause diarrhea, cramps, etc.

As some of the specific triggers of Irritable Bowel Syndrome (or anything that is diagnosed under that umbrella) may be unaccounted for, isn't it possible that there may turn out to be a link between a S. stercoralis and IBS?

Such a link could finally help to explain a lot of things for many people.

Someone needs to develop a reliable test for detecting an infection..

There is a reliable test for at least past infection (serum antibody). And while it would be nice to pin IBS down on strongy, the prevalence in the US is very VERY low, and the prevalence of IBS is quite high. Honestly, you could make a case for suspecting the exact opposite, that risk of IBS might be because of lack of strongy infections (or parasitic heminthic infections in general). Wouldn't be the first time that dysregulatory type phenomenon may be associated with lack of worms. See the hygiene hypothesis and autoimmunity.

Does anyone know, what is the lifespan of an individual S. stercoralis worm in the human host?

I believe the lifespan is 5 years, but the rather unique thing about strongy is that it can "autoinfect" basically unlike many other helmithic infections the progeny of the worms that live inside the host can reinfect the host, creating a continuous lifecycle within a single person. That way the strongy infection can persist for much much longer than the life of a single worm. For ID practitioners consider it a lifetime infection unless treated.

BTW, strongy is the common shorthand for it in the ID community. Would be awful annoying to have to keep saying S. stercoralis or strongyloides, or strongyloidiasis all the time. Way to easy to trip it up, to many sibilant S', strongy is short and sweet.

It can cause weight loss? How long before a quack sells encapsulated larvae as an all-new, all-natural weight loss miracle treatment?

You joke, however look up weight loss linked to gut microbiomes and realize you can take a couple of days of antibiotics(to kill existing gut bacteria), and then poop pills from someone really skinny(to get their gut bacteria), Combined with a diet similar to the skinny persons and watch the weight shed off, and stay off. If it starts coming back repeat the process.

After a while your body changes to produce the gut bacteria of being skinnier, and that can then be passed to your children.

Science and biology is awesome. even if things like this worm are disgusting.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

“However, the biggest challenge in fighting this disease,” they write, “is that many people have not even heard of the strongyloides worm.”

You ever hear the term "Ignorance is bliss"? I can now never "unknow" about this... thank you Ars.

I wonder, is checking for worms a routine thing that doctors do? Like whenever I take my cat to the vet they always make a big deal about checking for worms (of course my cad does occasionally eat her own sh!t so...), how often do human doctors check for such things? I have seen documentaries on parasites and it seems like checking for them is one of the last things that doctors do and some of the worst parasite infections don't manifest severe symptoms until they have already done permanent damage.

Having suffered from an infection by this parasite myself, I am somewhat surprised by the dire picture painted by this article. I picked it up at the Club Med in Cancun around 1981. (They were doing some beautifying in preparation for some upcoming world financial meeting, and I apparently stepped in some untreated fertilizer in my bare feet.) In my case, the symptoms manifested as very severe lactose intolerance. It took me a while to make the lactose connection. At a company physical, I mentioned the problem and the physician was not too optimistic about whether the normal tests would reveal anything. However, a few days later, he phoned me to tell me that my eosinophil count was very high, which is normally explained by a parasitic infection. So he ordered a test of a stool sample. I was very pleased when that came up positive for threadworm eggs. I was prescribed a round of Mintezol, the same drug as is used for worming pets by veterinarians. (It has a strong distinctive odor I had associated with vet clinics.) Instant relief. I asked the doctor about the lactose intolerance symptom. He was unsure but speculated that maybe I was borderline lactose intolerant to start with. Sure enough, a several years later, I did start suffering from lactose intolerance until I discovered lactase enzyme pills. I still don't really understand the parasite/lactose connection, but at least it alerted me to the infection, an infection for which the cure was quite simple.

“However, the biggest challenge in fighting this disease,” they write, “is that many people have not even heard of the strongyloides worm.”

You ever hear the term "Ignorance is bliss"? I can now never "unknow" about this... thank you Ars.

I wonder, is checking for worms a routine thing that doctors do? Like whenever I take my cat to the vet they always make a big deal about checking for worms (of course my cad does occasionally eat her own sh!t so...), how often do human doctors check for such things? I have seen documentaries on parasites and it seems like checking for them is one of the last things that doctors do and some of the worst parasite infections don't manifest severe symptoms until they have already done permanent damage.

Whether human physicians routinely check for intestinal parasites depends on location. In US practice most primary care doctors wouldn't check someone who is otherwise healthy, doesn't have any symptoms and hasn't traveled to the developing world.

BTW strongy hyper infection can occur in US veterans. It was acquired in the South Pacific in WWII and in Vietnam during that war.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Like with hookworm it all comes down to proper sanitation and wearing shoes.

Do you happen to know how far S. stercoralis can travel? Does it have the same limitations that hookworms do, where latrines off at least a specific depth would be safe?

Does anyone know, what is the lifespan of an individual S. stercoralis worm in the human host?

I believe the lifespan is 5 years, but the rather unique thing about strongy is that it can "autoinfect" basically unlike many other helmithic infections the progeny of the worms that live inside the host can reinfect the host, creating a continuous lifecycle within a single person. That way the strongy infection can persist for much much longer than the life of a single worm. For ID practitioners consider it a lifetime infection unless treated.

BTW, strongy is the common shorthand for it in the ID community. Would be awful annoying to have to keep saying S. stercoralis or strongyloides, or strongyloidiasis all the time. Way to easy to trip it up, to many sibilant S', strongy is short and sweet.

It can cause weight loss? How long before a quack sells encapsulated larvae as an all-new, all-natural weight loss miracle treatment?

You joke, however look up weight loss linked to gut microbiomes and realize you can take a couple of days of antibiotics(to kill existing gut bacteria), and then poop pills from someone really skinny(to get their gut bacteria), Combined with a diet similar to the skinny persons and watch the weight shed off, and stay off. If it starts coming back repeat the process.

After a while your body changes to produce the gut bacteria of being skinnier, and that can then be passed to your children.

Science and biology is awesome. even if things like this worm are disgusting.

It can cause weight loss? How long before a quack sells encapsulated larvae as an all-new, all-natural weight loss miracle treatment?

You joke, however look up weight loss linked to gut microbiomes and realize you can take a couple of days of antibiotics(to kill existing gut bacteria), and then poop pills from someone really skinny(to get their gut bacteria), Combined with a diet similar to the skinny persons and watch the weight shed off, and stay off. If it starts coming back repeat the process.

After a while your body changes to produce the gut bacteria of being skinnier, and that can then be passed to your children.

Science and biology is awesome. even if things like this worm are disgusting.

Like with hookworm it all comes down to proper sanitation and wearing shoes.

Do you happen to know how far S. stercoralis can travel? Does it have the same limitations that hookworms do, where latrines off at least a specific depth would be safe?

Just skimming around it looks like strongyloides doesn't go very far through soil (a few mm), but I haven't been able to find any primary literature on that so don't take that for very much. Wear shoes and use sewer systems people.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Sorry, I don't understand your comment. The article does not say, suggest, or even hint that a "huge dangerous epidemic waiting to happen." The headline refers the unforeseen life-threatening complications that can arise. And I don't understand why you think the article "somewhat over-dramatizes" the infection. The infection information is accurate.

The article is noting that experts are calling for more research and public awareness of a pathogen that is widely distributed and estimated to have a high prevalence. The prevalence estimates and the potential for deadly and unforeseen complications in some asymptomatic cases are a reasonable justification for making that call.

The thing about neglected diseases is that they lack sufficient research and data. You seem to be making the argument that this infection isn't a problem based on the data we do have. Yet, that data is not great--infection, detection, mortality. In some cases, people may not even be looking for these worms.

It seems unreasonable to me to use the dearth of reliable mortality and infection data as a justification for not worrying about this and pursuing more reliable mortality and infection data. And I'm not sure why US incidence data on a disease that predominately affects the developing world would be relevant in determining global public health research priorities, anyway. Last, I would think that even if the true mortality rates are low, it would be cold comfort to those who didn't even know they were infected before facing a life-threatening complication.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Sorry, I don't understand your comment. The article does not say, suggest, or even hint that a "huge dangerous epidemic waiting to happen." The headline refers the unforeseen life-threatening complications that can arise. And I don't understand why you think the article "somewhat over-dramatizes" the infection. The infection information is accurate.

The article is noting that experts are calling for more research and public awareness of a pathogen that is widely distributed and estimated to have a high prevalence. The prevalence estimates and the potential for deadly and unforeseen complications in some asymptomatic cases are a reasonable justification for making that call.

The thing about neglected diseases is that they lack sufficient research and data. You seem to be making the argument that this infection isn't a problem based on the data we do have. Yet, that data is not great--infection, detection, mortality. In some cases, people may not even be looking for these worms.

It seems unreasonable to me to use the dearth of reliable mortality and infection data as a justification for not worrying about this and pursuing more reliable mortality and infection data. And I'm not sure why US incidence data on a disease that predominately affects the developing world would be relevant in determining global public health research priorities, anyway. Last, I would think that even if the true mortality rates are low, it would be cold comfort to those who didn't even know they were infected before facing a life-threatening complication.

Beth, your first sentence is "A deadly parasitic worm..." and describe the risk of infection as "it can make its way into anyone, anywhere." Do I really need much more evidence to suggest that perhaps for dramatizations sake the article was overplaying the danger of strongyloidiasis? Is stronglyoidiasis a neglected tropical/3rd world disease? Absolutely. Would it be better to have greater understanding of its prevalence and better diagnostic and therapeutic modalities? Yes. Can it cause severe disease? Yes, but only in rare circumstances. Though the US has low overall prevalence of strongy infection and low incidence of new infections, prevalence in immigrant communities can be quite high and we DON'T see any major linked health problems in these communities either. You note that hyperinfection syndrome can occur with immunosuppression, but what you fail to clarify is that this is a very rare consequence of strongy+immunosuppression, not an inevitability, and THAT is what I was trying to make clear.

Using the term "a deadly X" can be very misleading to the lay public, because ANYTHING is deadly if you look for extraordinarily rare cases. Do we frequently state that people are drinking "deadly water" because people can in very rare cases drink enough water to cause death? I would think not.

Lastly, I will leave you with some advice. Part of the wonder of Ars is that you get experts in small fields weighing in with the knowledge and experience they carry. If they weigh in to clarify a point of nuance in your article, you should celebrate that and take pride in the fact that your article got their attention and promoted interesting discussion. Angry defensiveness only stands to make the community a less hospitable environment for such discourse.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Sorry, I don't understand your comment. The article does not say, suggest, or even hint that a "huge dangerous epidemic waiting to happen." The headline refers the unforeseen life-threatening complications that can arise. And I don't understand why you think the article "somewhat over-dramatizes" the infection. The infection information is accurate.

The article is noting that experts are calling for more research and public awareness of a pathogen that is widely distributed and estimated to have a high prevalence. The prevalence estimates and the potential for deadly and unforeseen complications in some asymptomatic cases are a reasonable justification for making that call.

The thing about neglected diseases is that they lack sufficient research and data. You seem to be making the argument that this infection isn't a problem based on the data we do have. Yet, that data is not great--infection, detection, mortality. In some cases, people may not even be looking for these worms.

It seems unreasonable to me to use the dearth of reliable mortality and infection data as a justification for not worrying about this and pursuing more reliable mortality and infection data. And I'm not sure why US incidence data on a disease that predominately affects the developing world would be relevant in determining global public health research priorities, anyway. Last, I would think that even if the true mortality rates are low, it would be cold comfort to those who didn't even know they were infected before facing a life-threatening complication.

Beth, FWIW, I thought the article was fine.

The title, however - "This gut worm is more common than malaria—and it’s a deadly, ticking time bomb" - certainly lends a more dire overtone to the article, IMO. I went into it expecting something completely different than was delivered. Which was fine, I liked the article, but I can see where the original poster was coming from, too.

I did take the immediate impression that superinfection with strongy was a common occurrence in immunosuppressed patients. The comments alleviated me of that misconception.

But I do agree with the majority of Beth's comments that the remarkable thing is the lack of data and how widespread it may be. Just the article terminology caused my speed-reading to miss the extreme rarity of the superinfection state.

Oookay. Lets get a bit of perspective with regards to how dangerous this infection is. While extraordinarily gross, Strongyloides infections are almost ALWAYS asymptomatic. There's a reason why it can infect so many people worldwide and not be a health concern on the scale of malaria. The major mode of prevention, is good sanitation. It sheds in stool (and will live in the soil where people have pooped waiting for someone to step on it). So if you have a good sewer system, even if you have people who are infected it will spread minimally.

So no, it's not a huge dangerous epidemic waiting to happen. The problem with strongy is it can persist as an infection for a long time (up to a lifetime), and if the person gets immunosuppressed in rare cases it can become strongy superinfection, which IS lifethreatening. Drug resistance is a concern, and steps should be taken to minimize its development, but this article somewhat over-dramatizes how dangerous strongy is.

Edit: FYI, strongy superinfection is VERY rare, even in people taking immunosuppressive drugs. There are 1-2 case reports a year in the US, and I can't find a published incidence rate on quick review. I guesstimate probably a total of ~10 cases a year in the US. This is not a raging problem.

Sorry, I don't understand your comment. The article does not say, suggest, or even hint that a "huge dangerous epidemic waiting to happen." The headline refers the unforeseen life-threatening complications that can arise. And I don't understand why you think the article "somewhat over-dramatizes" the infection. The infection information is accurate.

The article is noting that experts are calling for more research and public awareness of a pathogen that is widely distributed and estimated to have a high prevalence. The prevalence estimates and the potential for deadly and unforeseen complications in some asymptomatic cases are a reasonable justification for making that call.

The thing about neglected diseases is that they lack sufficient research and data. You seem to be making the argument that this infection isn't a problem based on the data we do have. Yet, that data is not great--infection, detection, mortality. In some cases, people may not even be looking for these worms.

It seems unreasonable to me to use the dearth of reliable mortality and infection data as a justification for not worrying about this and pursuing more reliable mortality and infection data. And I'm not sure why US incidence data on a disease that predominately affects the developing world would be relevant in determining global public health research priorities, anyway. Last, I would think that even if the true mortality rates are low, it would be cold comfort to those who didn't even know they were infected before facing a life-threatening complication.

Beth, your first sentence is "A deadly parasitic worm..." and describe the risk of infection as "it can make its way into anyone, anywhere." Do I really need much more evidence to suggest that perhaps for dramatizations sake the article was overplaying the danger of strongyloidiasis? Is stronglyoidiasis a neglected tropical/3rd world disease? Absolutely. Would it be better to have greater understanding of its prevalence and better diagnostic and therapeutic modalities? Yes. Can it cause severe disease? Yes, but only in rare circumstances. Though the US has low overall prevalence of strongy infection and low incidence of new infections, prevalence in immigrant communities can be quite high and we DON'T see any major linked health problems in these communities either. You note that hyperinfection syndrome can occur with immunosuppression, but what you fail to clarify is that this is a very rare consequence of strongy+immunosuppression, not an inevitability, and THAT is what I was trying to make clear.

Using the term "a deadly X" can be very misleading to the lay public, because ANYTHING is deadly if you look for extraordinarily rare cases. Do we frequently state that people are drinking "deadly water" because people can in very rare cases drink enough water to cause death? I would think not.

Lastly, I will leave you with some advice. Part of the wonder of Ars is that you get experts in small fields weighing in with the knowledge and experience they carry. If they weigh in to clarify a point of nuance in your article, you should celebrate that and take pride in the fact that your article got their attention and promoted interesting discussion. Angry defensiveness only stands to make the community a less hospitable environment for such discourse.

I'd like to see your credentials as Beth's are posted in her bio. Then we can decide who's more educated and knowledgeable about this. Initially I read your comments as "this poster seems to know a lot about this." Then you made your comment like you're an expert, so, back that up. If you're going to insult the author, prove you have the qualifications to do so.

Edit** Medicine and molecular biology as a profession don't tell me much, I can type anything into my bio too without any evidence it's true. Not saying it's not, you clearly have some knowledge but it's likely anyone with the google search bar can do that**

I'd like to see your credentials as Beth's are posted in her bio. Then we can decide who's more educated and knowledgeable about this. Initially I read your comments as "this poster seems to know a lot about this." Then you made your comment like you're an expert, so, back that up. If you're going to insult the author, prove you have the qualifications to do so.

Edit** Medicine and molecular biology as a profession don't tell me much, I can type anything into my bio too without any evidence it's true. Not saying it's not, you clearly have some knowledge but it's likely anyone with the google search bar can do that**

Attack the writer not what was written is always a convenient response. Fine, you want to know credentials?

Assistant Professor of Medicine in the Infectious Diseases Division at a Tier 1 Medical SchoolMedical Director of Antimicrobial Stewardship at a major national hospitalAssociate Hospital Epidemiologist for the same major national hospitalAssociate Medical Director for Infection Control at that same Tier 1 Medical SchoolBoard certified in Infectious Diseases and MedicineWrote chapter in most recent version of Mandell's Principles and Practice of Infectious Diseases (the bible of Infectious Diseases)

Beth, your first sentence is "A deadly parasitic worm..." and describe the risk of infection as "it can make its way into anyone, anywhere." Do I really need much more evidence to suggest that perhaps for dramatizations sake the article was overplaying the danger of strongyloidiasis? Is stronglyoidiasis a neglected tropical/3rd world disease? Absolutely. Would it be better to have greater understanding of its prevalence and better diagnostic and therapeutic modalities? Yes. Can it cause severe disease? Yes, but only in rare circumstances. Though the US has low overall prevalence of strongy infection and low incidence of new infections, prevalence in immigrant communities can be quite high and we DON'T see any major linked health problems in these communities either. You note that hyperinfection syndrome can occur with immunosuppression, but what you fail to clarify is that this is a very rare consequence of strongy+immunosuppression, not an inevitability, and THAT is what I was trying to make clear.

Using the term "a deadly X" can be very misleading to the lay public, because ANYTHING is deadly if you look for extraordinarily rare cases. Do we frequently state that people are drinking "deadly water" because people can in very rare cases drink enough water to cause death? I would think not.

Lastly, I will leave you with some advice. Part of the wonder of Ars is that you get experts in small fields weighing in with the knowledge and experience they carry. If they weigh in to clarify a point of nuance in your article, you should celebrate that and take pride in the fact that your article got their attention and promoted interesting discussion. Angry defensiveness only stands to make the community a less hospitable environment for such discourse.

I see your point that using 'deadly' can be alarming. As always, I would love to put in data and stats on mortality and risks to provide the clearest picture possible. But in terms of the frequency of hyperinfections, that data doesn't exist. There is, however, plenty of data to show that these quiet infections have the ability to turn deadly. The article mentions that most infections are asymptomatic and hyperinfections are conditional.

You keep mentioning US data to suggest hyperinfections are rare, but again, I'm not sure why it's relevant here. Even if that's true, developing countries have different healthcare settings, rates of infection, immunocomprised patients (eg HIV burden), and hyperinfections, and different outcomes in those cases. And any low figures exist in the context that these infections are neglected, under-diagnosed, and hard to detect worldwide. Moreover, hyperinfections can be hard to identify even while they're happening in healthcare settings, because they're often accompanied by sepsis, etc.

In other words, you raised the concern that I did not stress that hyperinfections are rare among immunocompromised. But my concern is that we don't have enough data to definitively say that. And that gets to the main point the experts were making: we don't have enough data on this common infection that can turn deadly.